Wiki A-fib Ablation with CAFE & Roof Line as well as A-flutter and AVRNT Ablation during same procedure

mcauffman86

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My provider performed an A-fib/PVI ablation (93656) along with CAFE and Roof line (93657 x2), ablation of a distinct arrhythmia mechanism (a-flutter 93655) and also ablation of AVRNT during the same operative session. Can 93655 be coded again for the AVRNT ablation. I see that the MUE for 93655 is only 1??

Preprocedure diagnosis: persistent atrial fibrillation

Post procedure diagnosis:

Persistent atrial fibrillation
Atrial flutter
avnrt
At (unidentified mechanism, likely left sided and macroreentrant)

Indication: Symptomatic atrial fibrillation refractory to drug therapy

Immediate complications: none

Procedure performed:
1) Comprehensive Baseline Electrophysiology Study with His bundle recording and electroanatomic mapping and PVI with RFA (Atrial fibrillation)
2) Carto 3-D mapping
3) Intra-cardiac ECHO
4) Additional focal catheter ablation after completion of pulmonary vein isolation (CAFE ablation)
4b) additional focal catheter ablation after completion of pulmonary vein isolation ( roof line ablation)
5) Ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism (Atrial flutter )
6) Ablation of avnrt
7) mapping of at with cl of 210 ms
6) Cardioversion
7) Isoproterenol
9) Ultrasound guided venous access

Patient arrived to the EP laboratory in the standard postabsorptive, nonsedated state. Gen. anesthesia was used for the procedure with endotracheal intubation being performed. Following adequate sedation, the patient was prepped and draped in the usual manner. Right and left femoral venous access was obtained using the modified Seldinger technique.
Heparin was then given throughout the procedure to maintain a therapeutic ACT around 300-350. Subsequently, a double transseptal puncture was performed using both a Preface and Vizigo sheath under the guidance of intracardiac echo with A BRK-1 needle. Carto sound was used along with fast activation mapping to re-create both left and right atrial 3-dimensional geometry while obtaining endocardial voltage.

Of note, the patient arrived in atrial fibrillation to the Lab. Catheters selective for the procedure included A Biosense Webster ST–SF Navi-Star catheter along with a Penta ray and coronary sinus catheter.

A Circa catheter was used to monitor esophageal temperature during the ablation procedure.

A wide area circumferential ablation was then performed around each vein in which both entrance and exit block was validated.

Following isolation we proceeded to perform
CAFE (Complex atrial fractionated electrogram) mapping and ablation. Ablation here included the septum and posterior wall. After this a roof line was performed and again the patient remained in atrial fibrillation and so a cardioversion was performed at 200 joules.

AT this point, roof line block was validated with a time of 130 ms.

We subsequently tested for afib induction with burst atrial pacing and induced an atrial tachycardia. Both left and right side were mapped. Cl of tachycardia was 240 with cs sequence of proximal to distal. Entrainment at the cti demonstrated typical atrial flutter and we proceeded to perform a CTI line which terminated the arrhythmia. Post ablation transithmus times were 150 ms in both directions.

WE again attempted to induce afib with burst pacing and with pacing around 200 ms, another at was detected with cl of 210. This was mapped in the right atrium first which did not prove revealing. Before mapping of the la could be performed, the arrhythmia did terminate.

AT this point, we used isuprel to look for both pv reconnection during this timeframe and atypical af triggers.
Isuprel infusion started at 5 ug/min and went up to 15 ug/min.
AT this point, brief runs of svt were detected with with cl of 340 and va time of 0. Further maneuvers demonstrated a diagnosis of avnrt and subsequently isuprel was turned off and slow pathway modification was performed. No av block was noted during slow pathway modification and accelerated junctional burns were seen on a few separate occasions

Burst pacing was used to look for induction of avnrt again but was negative. Isuprel was not retested given the
Prolonged procedure time.


At this point, ICE was used to verify the absence of any significant pericardial effusion

Going forward, we will reinitiate aad therapy and observe in the hospital overnight.
 
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